LETTERS
Jyh-Hsiung Huang, Address for correspondence: Pei-Yun Shu,
Cheng-Fen Yang, Chien-Ling Su,
Shu-Fen Chang, Chia-Hsin Cheng,
Sheng-Kai Yu, Chien-Chou Lin,
and Pei-Yun Shu
Author affiliation: Centers for Disease Con-
trol, Taipei, Taiwan, Republic of China
DOI: 10.3201/eid1511.090398
References
1. Powers AM, Brault AC, Tesh RB, Weaver
SC. Re-emergence of chikungunya and
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2. Powers AM, Logue CH. Changing pat-
terns of chikungunya virus: re-emer-
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vir.0.82858-0
3. Shu PY, Yang CF, Su CL, Chen CY, Chang
SF, Tsai KH, et al. Two imported chikun-
gunya cases, Taiwan. Emerg Infect Dis.
2008;14:1326–7.
4. Peyrefitte CN, Rousset D, Pastorino BAM,
Pouillot R, Bessaud M, Tock F, et al. Chi-
kungunya virus, Cameroon, 2006. Emerg
Infect Dis. 2007;13:768–71.
5. Yergolkar PN, Tandale BV, Arankalle VA,
Sathe PS, Sudeep AB, Gandhe SS, et al.
Chikungunya outbreaks caused by Afri-
can genotype, India. Emerg Infect Dis.
2006;12:1580–3.
6. Bonilauri P, Bellini R, Calzolari M, Ange-
lini R, Venturi L, Fallacara F, et al. Chi-
kungunya virus in Aedes albopictus, Italy.
Emerg Infect Dis. 2008;14:852–4. DOI:
10.3201/eid1405.071144
7. Pagès F, Peyrefitte CN, Mve MT, Jarjaval
F, Brisse S, Iteman I, et al. Aedes albopic-
tus mosquito: the main vector of the 2007
chikungunya outbreak in Gabon. PLoS
One. 2009;4:e4691. DOI: 10.1371/jour-
nal.pone.0004691
8. Santhosh SR, Dash PK, Parida MM, Khan
M, Tiwari M, Lakshmana Rao PV. Com-
parative full genome analysis revealed E1:
A226V shift in 2007 Indian chikungunya
virus isolates. Virus Res. 2008;135:36–41.
DOI: 10.1016/j.virusres.2008.02.004
9. de Lamballerie X, Leroy E, Charrel RN,
Ttsetsarkin K, Higgs S, Gould EA. Chi-
kungunya virus adapts to tiger mosquito
via evolutionary convergence: a sign of
things to come? Virol J. 2008;5:33. DOI:
10.1186/1743-422X-5-33
10. Schuffenecker I, Iteman I, Michault A,
Murri S, Frangeul L, Vaney MC, et al. Ge-
nome microevolution of chikungunya vi-
ruses causing the Indian Ocean outbreak.
PLoS Med. 2006;3:e263. DOI: 10.1371/
journal.pmed.0030263
1856 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 15, No. 11, November 2009
1-cm pustule that later turned into a
Research and Diagnostic Center, Centers for
Disease Control, Department of Health, 161,
Kun-Yang St, Taipei, Taiwan, Republic of
China; email: pyshu@cdc.gov.tw
Cutaneous Larva
Migrans Acquired
in Brittany, France
To the Editor: Hookworm-related
cutaneous larva migrans is a parasitic
dermatosis caused by the penetration
of larvae, mostly of a dog or cat hook-
worm, into the epidermis of humans
(1,2). This eruption is most commonly
found in tropical and subtropical ar-
eas but was recently reported from
western Europe, including Germany
(3,4), England (5,6), Scotland (7),
and southern France (8). We report a
patient from the Netherlands who ac-
quired hookworm-related cutaneous
larva migrans while on a holiday in
Brittany, France.
A previously healthy 40-year-
old man from the Netherlands trav-
eled to Brittany, France, to visit from
September 1 to September 15, 2008.
He and his partner slept in tents,
sometimes camping rough (not on
designated camping sites or on pri-
vate property), and they stayed in
low-budget hotels. They spent a lot
of time on several beaches along the
Atlantic Ocean on the southern shore
of Brittany (≈48°N). The weather
during their stay was variable. The
patient was frequently bitten by mos-
quitoes, especially on his feet. He had
not traveled to the tropics before and
did not own any pets.
After his return to the Nether-
lands, the area around 2 presumed
mosquito bites at the lateral side of
his right foot became red, swollen,
and itchy. This area evolved into a
bulla. On November 10, he visited
his general practitioner, who made a
diagnosis of cellulitis and started the
patient on amoxicillin/clavulanic acid
625 mg, 3×/day for 10 days. During
antimicrobial drug treatment, skin in-
flammation improved, but after 2 days
the patient noticed that an itching red
streak had developed, extending from
the lesions on the lateral side of the
right foot to the whole width of the
sole of the foot. The tip of the streak
proceeded along the sole of the foot
at the rate of 2 cm/day. On the fifth
day, he was referred to our Tropical
Diseases outpatient clinic.
Physical examination showed
2 elevated, ulcerative lesions on the
lateral side of the right foot, and from
each originated an elevated serpigi-
nous lesion (Figure, panels B and C).
These were typical tortuous lesions
2 cm in width. One of the lesions ran
across the whole sole of the right foot
and was 14 cm in length (Figure, pan-
els A and C). The medial end of the
lesion was fervently erythematous.
Based on clinical signs, we diagnosed
the skin lesion as hookworm-related
cutaneous larva migrans with second-
ary impetiginization. The patient was
subsequently treated with a single oral
dose of 12 mg ivermectin. The itch
and the progression of the lesion halt-
ed instantly and the lesion disappeared
during the following weeks. The larva
was not extirpated and thus not further
identified.
Hookworm-related cutaneous
larva migrans is usually caused by An-
cylostoma brasiliense, A. caninum or,
rarely, Uncinaria stenocephala. These
zoonotic hookworms need a high tem-
perature and a moist environment to
develop from an embryo to filariforme
larva (1,2). Hookworm-related cuta-
neous larva migrans is typically a dis-
order of tropical and subtropical zones
and it is rather common among tourists
who visit tropical beaches. This was
the first patient we had seen with this
disease who became infected in west-

Figure. Right foot of a patient from Brittany, France, with a hookworm-related cutaneous
larva migrans, showing an elevated serpiginous lesion on the sole of the foot (panels A, B)
and ulcerative lesions at the origin of the lesions on the lateral side of the foot (panel C).
A color version of this figure is available online (www.cdc.gov/EID/content/15/11/1856-F.
htm).
ern Europe. Apart from an exception-
ally hot day on August 30 (maximum
26°C), the weather was not particu-
larly warm during the summer of 2008
in Brittany; during the first 2 weeks of
September the average minimum and
maximum temperatures were 11°C
and 17°C, respectively. Rainfall was
moderate and humidity was ≈86% (9).
However, the overall warmer climate,
including warmer winters, might have
created the conditions for zoonotic
hookworm infections in humans in
western Europe (10).
Our patient may have been in-
fected by U. stenocephala, a nematode
of dogs that is common in temperate
zones but rarely causes hookworm-
related cutaneous larva migrans. An
increase in ambient temperature might
increase the incidence of these zoonot-
Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 15, No. 11, November 2009
LETTERS
Acknowledgments
We thank the Department of Medi-
cal Photography and Illustration of the
Academic Medical Center, Amsterdam for
providing the photographs.
Nienke Tamminga,
Wouter F.W. Bierman,
and Peter J. de Vries
Author affiliations: Academic Medical Cen-
ter, Amsterdam, the Netherlands (N. Tam-
minga, W.F.W. Bierman, P.J. de Vries);
University Medical Center Groningen, Gron-
ingen, the Netherlands (N. Tamminga); and
VU University Medical Center, Amsterdam
(W.F.W. Bierman)
DOI: 10.3201/eid1511.090261
References
1. Heukelbach J, Feldmeier H. Epidemiolog-
ical and clinical characteristics of hook-
worm-related cutaneous larva migrans.
Lancet Infect Dis. 2008;8:302–9. DOI:
10.1016/S1473-3099(08)70098-7
2. Hochedez P, Caumes E. Hookworm-relat-
ed cutaneous larva migrans. J Travel Med.
2007;14:326–33. DOI: 10.1111/j.1708-
8305.2007.00148.x
3. Kienast A, Bialek R, Hoeger PH. Cutane-
ous larva migrans in northern Germany.
Eur J Pediatr. 2007;166:1183–5. DOI:
10.1007/s00431-006-0364-0
4. Klose C, Mravak S, Geb M, Bienzle U,
ic infections in northern regions. Only Meyer CG. Autochthonous cutaneous
4 cases of hookworm-related cutane- larva migrans in Germany. Trop Med Int
Health. 1996;1:503–4. DOI: 10.1046/
ous larva migrans were previously j.1365-3156.1996.d01-86.x
reported in France, all from south- 5. Diba VC, Whitty CJ, Green T. Cutane-
ern regions (8). A northern spread of ous larva migrans acquired in Britain.
hookworm-related cutaneous larva Clin Exp Dermatol. 2004;29:555–6. DOI:
10.1111/j.1365-2230.2004.01592.x
migrans could thus point to expansion 6. Roest MA, Ratnavel R. Cutaneous larva
of the global distribution of the more migrans contracted in England: a remind-
tropical hookworms or altered condi- er. Clin Exp Dermatol. 2001;26:389–90.
tions that favor the emergence of in- DOI: 10.1046/j.1365-2230.2001.00841.x
7. Beattie PE, Fleming CJ. Cutaneous larva
fection by a zoonotic hookworm such migrans in the west coast of Scotland.
as U. stenocephala. Either explanation Clin Exp Dermatol. 2002;27:248–9. DOI:
calls for screening of infection in cats 10.1046/j.1365-2230.2002.09852.x
and dogs and preventing pet animals 8. Zimmermann R, Combemale P, Piens
MA, Dupin M, Le Coz C. Cutaneous larva
and possibly stray animals from ac- migrans, autochthonous in France. Apro-
cessing beaches. Clinicians should be pos of a case [in French]. Ann Dermatol
aware of the possibility of hookworm- Venereol. 1995;122:711–4.
related cutaneous larva migrans in 9. Weather in Brest, France, from Septem-
ber 1st to 15th, 2008 [cited 2009 Jan 25].
patients who have traveled to western Available from http://weeronline.nl/euro-
Europe and, in particular, those who stdf.htm
have stayed on the beaches.
1857
LETTERS
10. McMichael AJ, Woodruff RE, Hales S.
Climate change and human health: present
and future risks. Lancet. 2006;367:859–69.
DOI: 10.1016/S0140-6736(06)68079-3
Address for correspondence: Wouter F.W.
Bierman, Department of Internal Medicine, VU
University Medical Center, De Boelelaan 1117,
1081 HV, Amsterdam, the Netherlands; e-mail:
w.bierman@vumc.nl
European
Perspective of
2-Person Rule for
Biosafety Level 4
Laboratories
To the Editor: Recently, the di-
rectors of Biosafety Level 4 (BSL-4)
laboratories in the United States pub-
lished their views of the requirement
of having ≥2 persons present at all
times while biological work is under-
taken in a BSL-4 laboratory (1). They
concluded that safety and security
would be better assured in some situ-
ations by video monitoring systems
rather than by the presence of a fellow
scientist. As members of the European
Network of Biosafety Level-4 labo-
ratories (Euronet-P4) who have de-
veloped guidelines in this area (2–4),
we discussed the article during a re-
cent network meeting. Biosafety and
biosecurity are the major concerns
for all involved in BSL-4 activities,
and we support the authors’ initiative
and broadly agree with their posi-
tion. The consensus among European
BSL-4 experts is that, in the interest of
safety, standard practice should be for
all laboratories to perform a risk as-
sessment before any activity is under-
taken. This preliminary assessment is
the best way to determine procedures
to be used, including whether 2 per-
sons should work together as part of
1858 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 15, No. 11, November 2009
laboratory procedure. A 2-person rule
is inappropriate simply because the
best approach is not to have inflexible
rules that are not objectively assessed
according to laboratory-specific cir-
cumstances.
Surveillance video monitoring
and data storing have their place in
protecting laboratory facilities from
unauthorized access and theft of ma-
terials, but their effectiveness for en-
suring proper handling of pathogens
is quite limited. Finally, we agree with
the authors that both biosafety and
biosecurity must be founded on care-
ful selection and monitoring of staff,
without which even the most sophisti-
cated of control systems would fail.
Giuseppe Ippolito, Carla Nisii,
Antonino Di Caro, David Brown,
Robin Gopal, Roger Hewson,
Graham Lloyd, Stephan Gunther,
Markus Eickmann, Ali Mirazimi,
Tuija Koivula, Marie-Claude
Georges Courbot, Hervé Raoul,
and Maria R. Capobianchi
Author affiliations: National Institute for In-
fectious Diseases, Rome, Italy (G. Ippolito,
C. Nisii, A. Di Caro, M.R. Capobianchi);
Health Protection Agency, London, UK (D.
Brown, R. Gopal); Health Protection Agen-
cy, Salisbury, UK (R. Hewson, G. Lloyd);
Bernhard Nocht Institute for Tropical Medi-
cine, Hamburg, Germany (S. Gunther);
Institute of Virology, Marburg, Germany
(M. Eickmann); Swedish Institute for Infec-
tious Disease Control, Solna, Sweden (A.
Mirazimi, T. Koivula); and French National
Institute for Health and Medical Research,
Lyon, France (M.-C. Georges Courbot, H.
Raoul)
DOI: 10.3201/eid1511.091134
References
1. Le Duc JW, Anderson K, Bloom ME,
Carrion R Jr, Feldmann H, Fitch JP, et
al. Potential impact of a 2-person secu-
rity rule on Biosafety Level 4 laboratory
workers. Emerg Infect Dis [cited 2009 Jul
28]. Available from http://www.cdc.gov/
EID/content/15/7/e1.htm DOI: 10.3201/
eid1507.081523
2. The European Network of P4 Laborato-
ries 2005–2007 [Euronet–P4]. Brussels:
European Commission; 2008 [cited 2009
Jul 28]. Available from http://ec.europa.
eu/health/ph_projects/2003/action2/
action2_2003_19_en.htm and www.eu-
ronetp4.eu
3. Ippolito G, Nisii C, Capobianchi MR.
Networking for infectious-disease emer-
gencies in Europe. Nat Rev Microbiol.
2008;6:564. DOI: 10.1038/nrmicro1896-
c1
4. Nisii C, Castilletti C, Di Caro A, Capo-
bianchi MR, Brown D, Lloyd G, et al. The
European Network of P4 Laboratories:
enhancing European preparedness for new
health threats. Clin Microbiol Infect. 2009
May 28 [Epub head of print].
Address for correspondence: Giuseppe Ippolito,
National Institute for Infectious Diseases,
“L. Spallanzani,” 292 Via Portuense, I-00149
Rome, Italy; email: ippolito@inmi.it
Multidrug-Resistant
Mycobacterium
tuberculosis Strain
from Equatorial
Guinea Detected
in Spain
To the Editor: Eleven years of
molecular epidemiologic data allowed
the Spanish Multidrug-resistant Tu-
berculosis (MDR TB) Surveillance
Network to identify a specific MDR
Mycobacterium tuberculosis strain
that had been imported into Spain
from Equatorial Guinea (1). Our study
brings to light the potential dissemi-
nation of this strain (named MDR-
TBEG) in Equatorial Guinea, a coun-
try where little is known about the
extent and features of TB or MDR TB.
It also highlights that MDR strains
can spread across continents, and thus
MDR TB’s emergence in any country
becomes a global problem.
Ten MDR M. tuberculosis isolates
obtained from 10 patients from Equa-